Tuesday, November 29, 2005

I'm a big fan of Ellis Peters's Brother Cadfael novels. For the uninitiated, Brother Cadfael is a Welsh-born English monk who lives in the 12th century and who solves the mysterious crimes that are rampant in the town beyond his monastery walls.

Br. Cadfael came to the monastery after forty years as a Crusader, soldier, and sailor. He's conversus rather than oblatus, which makes for some interesting perspectives (his) on the nature of the Benedictine order to which he belongs, the nature of Divine justice, and the vagaries of humanity.

One thing Cadfael has is certainty. He's certain about the existence of God, the fact that His justice will eventually prevail, and that sometimes humans have to act as God's hands in daily life. He's certain that he can heal the sick (Br. Cadfael is the herbalist and assists the infirmarian in his duties) and bring wrong-doers to justice. Most of all, he's certain of his place.

"We do what we must, and we pay for it. So in the end, all things are simple."

That's a line from the last Brother Cadfael novel, in which he goes recusate in order to rescue his son (conceived during the Crusades) from death.

Being in this business has made me aware that most things are far from simple, far from certain. I envy the certainty that my pal the chaplain has, that all things are for the best. I envy the simplicity that allows a person to see that their life has reached its effective conclusion and thus refuse further care.

I'm thinking of spending a week or so at a convent somewhere. I'm not sure whether it'll be Benedictine or Buddhist, but I think the silence would be useful. Not as a way to reaffirm vocation; as Opus Dei advocates, the vocation I've chosen sanctifies itself every day. Perhaps as a way to settle doubts; whether or not there's some Universal Being up there, it makes sense to decide whether to believe or not, once and for all.

"Agnosticism as a belief system is akin to immobility as a form of transportation."--Life of Pi

For some reason the thought of a week of silence, discipline, and thought is sounding better and better every day. Not as a retreat, mind you, in the typical sense of the word, but as a regathering.

1. Moxie Fruvous might be the best band to cook to. Better than Indigo Girls, better than Joni Mitchell, even, though I prefer Joni Mitchell when I'm baking bread. There's something about "King of Spain" and the little shimmy-dance you can do to it that makes chicken pot pie come out really well.

2. The attitude of any given employee of a medical facility is inversely proportional to their skill. That observation includes me.

3. Every child should be taught touch-typing at a young age.

4. Sr. Cathleen and Sr. Mary Catherine of the Benedictine convent in Clyde, Missouri, make great lotion bars and soap. Green Tea scent is my favorite.

5. Brushing the top of your biscuit dough with a mixture of milk and melted butter (sorry, no exact proportions) will make the biscuits stay crunchy even in the microwave.

6. It is good to spend at least one afternoon of your days off in pajamas.

7. Honor Harrington (On Basilisk Station, A Short and Victorious War) undoes all the damage that years of Heinlein and Asimov females have done to me.

8. My boyfriend's sister-in-law is pretty cool for lending me her treasured copy of the first Honor Harrington story.

9. Anybody who feels that an IV-start certification will get them anywhere is probably sadly mistaken.

10. My cat is extremely strange. I have had nothing whatsoever to do with this.

Monday, November 28, 2005

For the first time in more than a year, I have had a bona fide bad day at work.

It's rare to have a truly bad day. I mean, the day the medication dispenser went down and I couldn't get antibiotics for a patient with fulminant meningitis was pretty bad. The day a patient's family member assaulted me was pretty bad. And yesterday was pretty bad. Three in three years, though, is a good ratio.

Start with a pimple. Put it somewhere sensitive, like between your upper lip and your nose, and make sure that it's painful. It doesn't have to be big, or noticeable, or ugly, but it does have to be painful.

Then, when you wake up, make sure you're not feeling up to snuff. Something must've blown in on the wind night before last, because when I woke up yesterday, every cell in my body was poisonous to every other cell. It felt like a hangover without the alcohol.

Add one patient who seemed determined to seize, code, and die. Before 8 am.

He'd come in with a particularly nasty aneurysm that was snuggling up against his brainstem. Three hospitals had told him the thing was inoperable, but we figured we could either go in through his basilar or femoral artery and at least coil the thing. Turns out that genetic roulette had cursed him with arteries so torturous that we couldn't get to where we needed to be remotely; we had to go in and clip the damned aneurysm in an open surgery.

Which was a success, and not just in the "the operation was a success, but the patient is now trached and tubed and gorked" sense. It was a success in that he could move everything better when he came back than when he left, he knew where he was, and things were looking up.

Until that seizure. I didn't see it; the aide was feeding him breakfast and, for a split second, thought he was choking. She wisely yanked the emergency cord out of the wall and we all converged on the room. By the time I got there, the patient was already post-ictal and nonresponsive even to pain, but with a blood pressure in the high 200's.

And respirations of less than eight a minute. And a number of other little quirks that made the aide roll the cart down to the room, just in case.

I'll spare you the details of labetalol, large-bore IVs, and external pacing.

His daughter, when I called her, immediately asked me if the seizure was a result of her not coming to visit the day before. Yes, she's one of *those*. I went with the resident when she went in to see Daughter and tell her what was up with Dad; I figured somebody had better be there to stem the tide of hysteria and keep the resident from getting stuck in the family room. And yes, it was just as bad as you might imagine. Thanks for asking.

Shortly after I got him to the ICU, I got sent to another floor. Not because of my skill in keeping other people from going to the light prematurely, but because of staffing issues.

I was immediately presented with two patients fresh out of the unit after inguinal lymph node dissections and assorted other things. One guy had had a penectomy (yes, that is exactly what you think it is) for cancer; the other had had his bladder removed for the same reason. Urology is okay, it's interesting and fun, but I hate cardiology.

So when Mister No-Bladder Person started throwing PVC's (this is a very bad thing) in couplets and triplets and generally making the monitor sing pretty songs, I started hating things. A dose of IV metoprolol regulated his rhythm and made me hate things less...until his blood pressure started rising. And rising. And rising some more.

It came down after forty milligrams of hydralazine. To 185/100. An improvement, but not enough of one. So here we go again with the bleeping labetalol and the monitor going nuts and now the patient is sundowning and trying to get out of bed, uncapping drains and yanking catheters and generally being difficult.

At some point in the middle of all of this, Chef Boy called with the news that his gate had blown open and his Dachshund was somewhere in the city, wandering. Somehow this was my fault, he implied in a snarky voice mail message, even though *he's* the one with the house and the gate.

Did I mention the particularly painful and distracting pimple? I thought so.

Finally things calmed down. Mister No-Bladder Guy got his Haldol and went to sleep. Mister Penectomy Guy quit sending his obnoxious wife out to the station with demands for more pillows (you have eight in the room; how many more do you need?) and I got his potassium running and his blood sugar (480) dealt with.

Wednesday, November 23, 2005

Even though we get a good lunch--and dinner, if we want it--for free, I still prefer to take my own breakfast to work on holidays.

Herein is Jo's Diner Breakfast, gleaned from the days when I was a Dinette at Jim's ("You don't need no teeth/to eat the beef/At Jim's Diner"; "If you got it, share it; don't smoke it in the bathroom, man."):

One raw potato, peeled and cubedTwo eggs, beatenA few shreds of onionA handful of shredded hamWhatever cheese is to your liking

Set your biscuit dough up and cut it out. Stick it in the oven to bake.

(There are numerous recipes for biscuits; even Bisquick makes a decent biscuit if you eat it hot. Try Brother Juniper's Fluffy Biscuit recipe for a Yankee version or search "angel biscuit" on Google for a Suthun version.)

Fry up your ham and onion until the ham begins to brown.

Scrape it out of the pan and dump the eggs in. When they're settin' nicely, put your sliced or shredded cheese on 'em and dump said ham and onions back on top.

Fold it all over and wrap it up into an omelette when things look good and ready. Don't ask for more specific instructions or Terry the Drunken Cook will go after you with a spatula.

When that's done cookin', stick it into a Tupperware and put it into the fridge.

Parboil your cubed potatoes until they're almost done, then season 'em with seasoned salt (or paprika, salt, garlic powder, and cayenne, in that order).

Slide a quarter-cup of oil into that hot pan you cooked your omelette in. (Yes, I know that's a lot by today's standards, but this is *diner* cooking.)

Dump in your seasoned potatoes. I hope you have a good exhaust fan over your stove.

Cook until they're crispy on the outside, mealy on the inside.

Drain on paper towels. If you're in the diner, you can skip that step.

If you're really hurtin' for gravy, now's the time to make it, with sausage grease and flour in a roux, milk, and more flour to thicken. (You do keep sausage grease on hand, right? In an old coffee can? What are you, some kinda hippie?)

Take the biscuits out of the oven. Let them cool on the counter, then wrap two up in foil. Put your putative gravy in another Tupper, and your now-cooled and drained potatoes in yet another.

Pack the whole caboodle into your bag to be assembled in the morning. Don't forget the jelly.

That kind of cooking shouldn't be eaten every day. Fo' sho'. But for charming Rainbow Children who are hitching from Austin to Portland, Maine for the blueberry harvest, or satisfying old truck drivers or cement layers from the South, nothing can compare.

This year we're having turkey, cornbread stuffing, greens, and pumpkin pie. In homage to the recently displaced Louisianians we've got working with us, those same N'Awlinians have agreed to come in to cook crawfish etouffe, dirty rice, and bread pudding for us.

Happy Thanksgivin', y'all. I have a beer in my belly, a cat in my bed, and Jim's Diner cooking in my fridge for tomorrow.

Monday, November 21, 2005

After that last post, I feel the need to reassure everybody that I'm not some sort of deep-thinking, intelligent person. Therefore, I present this week's product reviews:

Gray's Anatomy

Really. Who watches this? I mean, who watches it *seriously*, without laughing at the unintentionally funny moments, like when the surgical intern breaks sterility while working on his dad's butt? Or when the neurologist suddenly performs brain surgery? Or when that same neurologist/neurosurgeon/whatever tells a patient that he has a fifty-fifty chance of surviving surgery to evacuate an epidural hematoma?

Note: This is why you don't have actors performing neurosurgery.

Plus, all the surgical interns on that show look older than I do. I mean, come *on*, casting directors--the residents I work with look about eighteen, the interns even younger. Why have a rode-hard, put-up-wet bunch of young actors who are supposed to be looking young and idealistic?

Judgement: avoid.

Mr. Clean Magic Eraser cleaning sponges

I'm probably going to lose my crunchy-granola badge for this, but these things rock my world. I have no idea what's in 'em, probably PCBs and DDT and fiberglass, but they really do work well. You know those smudges on the wall around the light switch? They take those off. Ditto soap scum of undetermined age on Chef Boy's bathtub.

The only problem is that they're meant to be disposed of. Seems wasteful to toss 'em out after only five or six uses.

But damn if they don't clean well.

Judgement: good, but in small quantities.

Ryka walking shoes (women's only)

Get the wide if your feet are at all normal. If they're really skinny, get the regular. Expensive, but comfortable on the track and at work, though not as nice as the Columbia light-hikers I got on sale a couple of years ago.

Judgement: nice, but pricey. Do not purchase through mail order.

Faux Frog Chardonnay, 2001

The only Chardonnay I've ever tasted that has an aspartame-like finish.

Judgement: run away, run away.

Harry Potter and the Goblet of Fire

Shortened considerably from the book, naturally, but still a good ride. Hardly any Malfoy. Lots of Hermione. Moaning Myrtle makes an appearance, and I think they used a body double in the bathroom scene. The costumes are wonderful. Ralph Fiennes is balletic in his evilness.

Judgement: see, preferably at one of those movie places that will serve you a nice glass of Blue Paddle or two.

Friday, November 18, 2005

In that sentence, in that thought, the plural form is the strangest part.

I've been doing the death-in-the-headspace thing a lot lately, partly because of my patients and partly because of my aunt.

A side note: the previous entry, the one that Jodi responded to, had a long section about the decision my aunt made earlier this week to die. After I'd posted it, I got an email from Mom saying that she had indeed died, early this morning, and so I edited that portion out. It seemed inappropriate, somehow. She'd made her decision and followed through, and I didn't want to dissect it after the fact.

Anyway, back to the death-in-the-head thing.

The most sobering thing about doing what I do for a living is this: it means that I have done something that, as far as I know, the rest of my immediate family has not. I've done it enough that it's become, at least in the outlines, fairly routine.

I've hugged family members. I've answered the call bell or the person who comes out into the hall with *that tone of voice* or *that look* that means that the person in the bed has quit breathing. I've caught up another nurse on the way to the room to verify the lack of a heartbeat. I've called more residents than I care to think about to verify our verification and chart time of death. I've walked them through the paperwork and told them where to sign.

And, more than that, I've been alone with a number of dead people. The dead are peaceful; they don't ask for cups of coffee when they're NPO or talk politics. I've bathed bodies, removed tubes and wires and IVs, wiped off things I couldn't identify and would rather not think about. I've talked to those people as I've done it, hoping that maybe my persistence in treating them as a living person would speed their souls on to wherever souls go.

I always leave the window open when I do this, no matter the weather. If I have a soul, and if it leaves my body after I die, I do not want to have to work to get outside and fly away. No elevators for me; give me an open window. Supersitious, yes, but part of the private ritual I have.

None of this is stuff my parents have done. My folks, who have a wider experience of life and a much greater understanding both of how stupid and how wonderful people can be, have not (to my knowledge) been around when somebody's died and then taken care of the body. I know my sister hasn't, or I would've heard about it already.

More than that, I've done it *multiple times*. Which is a stunner, when you think about it.

It opens an experiential gulf that I'd not thought about before today. Those of us who midwife the dying are a weird group; we're not generally skeeved out or frightened by the thing that is most taboo in our culture. Most of us have dissected at least portions of bodies; all of us have talked to those still living about the process of dying. It's hard work, as hard as having a baby, and with much the same rhythm as birthing.

The people who understand that, who don't get flipped out by the thought of a person not being immediately available in the body, tend to get chosen for the palliative care assignments on our floor. Oh, yeah, we always give the newest nurse a couple of DNRs who are about to go, just to make sure they can handle it, but after that, there's a cadre of us who seem to get assigned the dying and soon-to-be-dead over and over.

We self-select through our attitudes and our actions. The folks who make the assignments recognize that.

There's still a part of me that wonders, every time one of my patients dies, what on earth those idiots at the nursing school were thinking when they gave me my degree. What made them think that I could do this well? Why am *I* the one that has to be the shoulder and comfort for the living? I ask that not because it's a burden but because I feel so unqualified. The person who takes care of your dying father should be unflappable. Calm. Sympathetic but not overwhelmed by emotion. Distant enough to give you privacy, but not appear cold. I feel too imperfect, too undeserving, to do that job.

And every time, that gulf that lies between my and my folks and my sister, between me and Chef Boy, between me and the other average Janes on the street, grows a little wider. It gets a little deeper.

But I don't worry. I have the gut feeling that this is a gulf that will eventually grow wide enough that I'm back on the same side as everybody else. It'll be more like a discarded orange peel and less like an enforced distance. It'll be interesting to watch that process happen.

He came to us four weeks ago with a tumor in his cervical spine. The surgeons resected as much as they could, placed hardware in his spine to keep his head erect, and arranged for him to start radiation therapy.

He came back last week, unable to hold his head up. An MRI showed that the tumor had returned, aggressively, covering and wrapping around the hardware we'd placed recently enough that his scars were still pink.

He's in his forties, with two kids. His wife had to make the decision to withdraw care, and had stayed with him since then. He was breathing near-pure oxygen last night through a mask, in short gasps, his ribs and intercostal muscles showing with every breath. The place in his skull where we'd taken out a bone flap after a brain biopsy was sunken. His wife curled against his chest and talked to him, telling him it was okay to relax, to go, to let go. For her, there was nobody else in the room.

I thought about that as I stood looking at the syringe of morphine I was holding. I'd just drawn it up; his wife had come to me saying that he looked as if he was about to go, and like it was hard work. Could he, she asked, have a little more morphine to ease his breathing?

He was already on a drip--not a lot, but enough to calm the demands his heart was making for oxygen.

You're taught early on that it's not unethical to give pain medication to people in palliative care, even if the amount of medication they receive might hasten their deaths. It's a decision about quality of life rather than quantity, and it's acceptable: no one wants to deny pain medication to a cancer patient in fear that they might either die sooner or become addicted. By the time you hear the word "palliative", it's too late to worry about addiction.

It's a different animal, though, when you're standing in the med room five minutes before shift change (a fact you note with only a part of your attention; at times like this, punching out doesn't matter) with a possibly-lethal dose of morphine in your hand.

If I give him this morphine and he stops breathing, how will I handle it?

He knew what he wanted; his wife knew what he wanted. There would be no problem for him. Not breathing for a few hours more would be no skin off his nose. Knowing the patient, he'd probably--if he were still aware--thank me for the favor.

But his mom and dad? His kids, standing at the bedside? His wife? Me?

There's a big difference between knowing something is ethically clean when you read it in a textbook and pondering the reprecussions when it's you that has to make that decision.

I gave him the full dose of morphine; he kept on breathing. The reprecussions were delayed for a bit in that case.

I wasn't comfortable with the morphine for a number of reasons, mostly because it seemed that I had the potential to cut short some sort of necessary process. Who knows what's happening to somebody else, what sort of transition they're undergoing, as they die? The old-fashioned pillow-on-the-face trick might leave them unprepared to do whatever the hell it is we do after we stop breathing. Either way, why is it my decision? Why is it my responsibility?

And there in black and white is the hardest thing about being a nurse: not accepting that a beloved, brilliant person has decided not to go on living, but realizing that at some point, you may have the task of helping them out, incidentally and unintentionally.

Tuesday, November 15, 2005

1. If your nurse is trying to get a history from you, it's not the time to answer your cell phone, order a pizza, start manicuring your nails, try to set up your 'Net connection, or take calls from your constituents.

2. Likewise, if you're the family member of a patient who has global aphasia (think: unable to speak, write, or comprehend; limited only to pleasant smiles and gestures), now is not the time to book it toward the exit door. Stick around. Knowing what Mom is allergic to is really nice in these situations.

3. If you are one of those people lucky enough to have an entourage, whether privately or publicly funded, they're going to have to leave the room during the exam. The gentleman with the expensive suit, earpiece, and suspicious lump in the armpit of his suit will not tell me more about your neurological status than I can find out on my own.

4. A special note for elderly Yankees, or those who have moved to Florida: I don't know what kind of nurses they have in your universe, but I am not "the girl." I am not a waitress, maid, personal secretary, dogsbody, factotum, or whore. I have a particular job to do, and you're not making it much easier. Plus, the amount of money you donated to the hospital makes little or no difference to me. You're still gonna get stuck.

5. Speaking of needles, I don't care who you are. You don't get to refuse the urinalysis, the IV start, the fluids, getting weighed, the CT scan, or the bloodwork. You are ill enough to be in the hospital; this is what we do in the hospital. I won't argue with you, either; I'll simply tell your surgeon that you're refusing treatment, and you can go home, enormous bleed/fulminating meningitis/giant tumor and all.

6. Please bring your medications, or a reliable list of them, with you to the hospital. This helps me in two ways: I don't have to butt heads with my beloved pharmacists about what sort of small, blue pill you might be taking for your sugars, and (more importantly) it lets me know what sort of person you are. If I see that you have a mostly-full bottle of Cipro with you that your doctor prescribed for you to take "when I'm not feeling well", and I see the name of a tough-as-nails, take-no-prisoners internist on the label, I will immediately know that you're the sort of obnoxious bully who's worth risking a resistant infection for rather than arguing with.

7. Please don't bring anybody else's medication with you. I don't care what Papa takes, only what you do.

8. And for God's sake, don't hide stuff in your bed. I *will* find it and you *will* have it taken away from you. There are doctors who will write orders for a Scotch and soda before bed. Find one.

9. Don't abuse your privilege. I'm talking here about the patients who threaten to call the president of the hospital if there's something they don't like (the food, the resident, the fact that they have to get fingersticks to check their blood sugar). I'm also talking about patients who call out on the call bell and say things like "Goddammit, you idiot, I need you in here RIGHT NOW to adjust my bed!!" (verbatim quote.)

10. And finally, be nice to the support staff. The woman who cleans your room is not (verbatim) "that cute little nigger." The people who transport you from place to place don't lack brains or ears. The person who brings your tray, sets it up for you, and helps you get started on your meal deserves at least a "thank you" for her trouble.

The sad thing is that none of the people referenced above were demented. None of 'em had troubles that would have affected their thought processes. They were just *like* that.

There are dozens of people, of course, who are genuinely sweet and pleasant; the sort of folks that you grow to love in the week that they're with you. Unfortunately for everybody, the assholes of the world are louder and more persistent.

Oh, well. The meek might not inherit the earth, but as long as they're not on a restricted diet, they'll inherit whatever treats and tidbits the nursing staff brings them to tempt their appetites.

Monday, November 14, 2005

It is a signally bad idea to eat four slices of artichoke-heart pizza and drink a pint of Winter Ale, no matter how hungry you are, then sleep for two hours with a Dachshund perched on your butt, no matter how sleepy you are after your pizza orgy. Waking up in a hot bedroom with a snoozy Dachshund draped over your hip will make you groggy, grumpy, and unlikely to be cheerful when your boyfriend suggests going swimming.

So I'm blogwhoring instead, having cleaned my house and drunk a pot of coffee and generally worked back up to feeling half-human.

I had not known of Globe Of Blogs until tonight. Check it out. Mia's blog Death Maiden is listed, as well as some other interesting nurseblogs. There's at least one interesting-looking single-focus patient blog, as well.

Thursday, November 10, 2005

Anonymous comments are back. Both Mom and Vi had trouble commenting without 'em. The trouble occasioned by the rare anon troll is worth having their comments here. Mom, try the names I made up for you, okay? Okay.

Trolls: If you show up here, I will find you out. I will then put you on 180 mailing lists for sex toys that will follow you until the day you die. Alternatively, I will figure out which way you voted in your last local election and put you on 180 mailing lists for the opposite political camp. Be warned. I ain't doin' no Bitch, PhD thang here. I go straight for the jugular.

If you've sent me email in the last few days, I've not answered because (again) my Internets have been down. I've added Geek Nurse to the sidebar, more in appreciation of the Camera Whose Name Shall Not Be Spoken than because the Geek himself asked. Check it out. It's worthwhile. And it's the only Peds-related link I have.

If Mama is 87 years old, demented, obese, with long-standing heart troubles and CAD, a less-than-ideal immune system, and unable to make sense of what's going on, it might not be such a good idea to have her hip replaced.

Especially if the outcome--a six-day stay in the ICU, a raging infection, and general misery for all--is one you've been warned about beforehand.

I'm just sayin'. Mama is going to be lying in bed for the rest of her life anyhow, not knowing where she is, alternately screaming and cursing, Foley and O2 mask and rectal tube and permacath in place, regardless of what you do. Quality of life here is an issue. Would you rather Mama be in pain with a huge fever, in a strange place, with invasive things done to her, or in *controllable* pain in a familliar place, with less likelihood of dying in fear?

If anybody ever does that to me, I will make it a point to die on the table and then haunt them for the rest of their lousy lives.

What a Young Nurse Should Know

Strokes do not necessarily change a person's personality. If Papa is a racist now, after one of his frontal lobes got bludgeoned by a big ol' clot, it's likely that he always had those attitudes, but also had the socialization to keep them to himself.

Likewise, if Auntie is dreadfully unpleasant now that she's lost her right parietal lobe and part of her frontal lobes, it's very likely that deep down, waaaay hidden away, she was pretty unpleasant to begin with.

The trick is to accept the family's apology for Papa's or Auntie's behavior without pointing out to them that you took care of Papa or Auntie last year, prior to this stroke, and not much has really changed.

Nobody told me there'd be days like this...

It has been a hellishly long six days. The two days I've had off in the last eight, the 'Net was down here at Las Casas Del Nonrobust Connection, so I've not been able to blog. That's probably just as well, because any writing I'd be able to produce would sound a whole lot like a drunk running into a wall at 3 a.m.

There are days in nursing when everything goes smoothly, you get your charts opened by nine, you have a chance to eat and even maybe drink a mid-afternoon cup of coffee, and you feel good when you leave the floor. There are other days, when nothing specifically horrible happens, but everything gets all wadded up in a huge ball that takes you hours to untangle. The last six days have pretty much been the latter sort.

It's not that the work recently has been particularly demanding in a physical or mental sense. After all, I'm not the one who has to localize somebody's stroke on the basis of symptoms or read their EEG. There have been no six-hundred pound patients falling out of bed lately (thank God and knock wood). It's just that little, simple things, like accessing a Mediport, took on a new and complicated dimension this week.

The Mediport (a permanent, implanted catheter under the skin of the chest through which one can infuse medications and draw blood) would flush, but not draw. This necessitated my trying to unclog it with TPA and failing, then ordering a chest X-ray, as per hospital protocol. Meanwhile, the patient whose Mediport it was was getting itchier and itchier (liver failure will do that to you) and more and more anemic. All of the falderal about TPA and chest X-rays was necessary, as I didn't want to run a couple of pints of blood into somebody's chest wall unless I was ordered to do so.

Then the one respiratory isolation room on our floor got bolloxed up somehow, so that the exhaust wasn't going to the outside air, but instead to the floor in general. Which would not have been a big deal had somebody discovered it *before* we'd put a possible TB case in the room. Again, not a big deal from a health standpoint, since it'd take a person about a million years of overtime to catch TB from the diluted particles that were exhausted into the air, but a cluster-fuck from a logistics standpoint.

Then the post-op unit sent me the wrong patient. I was waiting for an angiogram and got a belly surgery. Oops. More Three Stooging ensued, with the patient going to another floor, everybody smiling in a rictus of horror and trying to make like we'd planned it that way, and my promising, in a tense whisper, to skin the PACU nurse who'd messed up.

It seems the Universe knew I'd bought a fresh bottle of Bruichladdich.

...Most peculiar, Mama.

The differential diagnosis crew will be hard at work for the rest of the week.

MS behaves differently in different people, that we know. Sometimes you see the characteristic plaques in the brain on MRIs, sometimes you don't. Sometimes there are exacerbations and remissions, sometimes there aren't.

But MS does not behave like this:

An eighteen-year-old male presents with a six-month history of pain in the legs and decreasing coordination, especially truncal control.

Fast forward a year, to the latest exacerbation of what's been diagnosed as MS, despite no clinical evidence: the patient shows a persistent left-going gaze, still complains of intolerable pain in his legs and arms, the use of one side of his body. He never got better, not for one single day, in the intervening year. His family is now reporting personality changes, aggression, fearfulness, and aphasia.

His MRI signal is abnormal in the hippocampus. His EEG is insane.

We're all being very quiet on the floor, waiting for the neurologists to take a brain biopsy (not very useful, as you'd have to get very lucky to get what you need in a single cut), get the results back from his lymph node biopsies, and make a diagnosis.

My Favorite Martian (aka one of the best, most pleasant, least weird neurologists on staff) looked at me with a very solemn expression the other day, after he left my patient's room. He said nothing. I said nothing. Then we went down to the station and, together, ordered all the biopsies and reserved all the ORs that he would need for the next week.

We think we know what it is, and we really hope we're wrong.

Ending on a hopefully-more-cheerful note

The fact of the matter is, I'm not dead. The flu shot I got might've caused me to be sore and grumpy for the last two days, but grumpy and sore are my usual personality traits, so nobody much cared.

I'm off for three days, on for one, then off for two. On the last day of my mini-vacation, I'll be attending a monstrously wonderful pre-Thanksgiving potluck for the third year straight. We get such marvels as biriani and tabbouleh, enchiladas and that weird corn/mayonnaise/chili powder/lime concoction so beloved in Mexico, spring rolls and squid and dried fish. Somebody always fries a turkey, as a concession to the Suthun way of doing Thanksgiving, but we can eat barbecue instead if we like.

The New Car continues to be amazing. I fill it up once every couple of weeks, drive it around while I play with all the nifty automatic settings for this and that, and consider my $380 per month well spent.

They charged me the price of a ten-year Scotch the other night when I picked up the Bruich. It's actually a 14-year. And, because I am the original cheap drunk, I can expect that it'll last me at least three more months.

Not one word about Alito. I swear. Just go read PinkoFeministHellcat on the subject that's attracting the most attention. Oft thought, but ne'er so well expressed.

And please, please don't get me started on civil rights, disability rights and access, and gender equality.

We all knew Miers would be a sacrificial lamb, and that once she withdrew or failed to be confirmed, Bush would come out with his *real* candidate. Now he has, and now things will get interesting.

A word on judicial bypass

The state in which I live requires parental notification for minors seeking abortions. In the years I worked in women's health, I only saw a handful of cases in which young women who had to notify their parents were unwilling to do so, for very good reason.

One case involved a young woman whose father and stepmother had looked the other way while she was raped repeatedly by a cousin. Another involved a girl whose father would've killed her, literally, for bringing shame on his family. Those were the two worst; there were four or five more that, while not as horrible, certainly presented food for thought and caused me to call the equal-access folks for help.

Now, then. Judicial bypass is an option for young women in this state...but there is not one judge in my county who will hear a judicial-bypass request. Not one. They've all decided that judicial bypass takes the rights of parents away. Unfortunately, it's difficult to get a bypass ruling from a judge not in one's home county, even with competent legal help.

It's accepted that parents have a certain amount of dominion over their minor children; that's how parental consent and notification laws have passed in so many states. The spousal notification and consent laws that have been struck down assume that men have the same dominion over their spouses.

Which is a silly assumption, especially considering it doesn't go both ways.

Imagine what it would be like to be living in a county with no judicial bypass option, as a married woman with an abusive spouse, or one who's simply disappeared, or one who's locked up somewhere, and trying, as an adult woman, to get basic, common health care.

Imagine how it feels to be told this: even if you're in a good relationship, even if you and your spouse have made the decision not to continue a pregnancy together, you still don't have the ability to make that decision on your own, simply because you are the one carrying the pregnancy.

This is just like pharmacists refusing to dispense the morning-after pill, people. The onus falls on women in every case. When you show me the cases involving pharmacists refusing to dispense Lipitor or Levadopa to men, or the cases in which men are required to notify their wives before undergoing a radical prostatectomy, then I will believe that all this is about moral repugnance or equalizing voices within a relationship.

Until and unless that happens, I will continue to think that perhaps, just maybe, just a little bit, these sorts of things are about not allowing women full power over their bodies and their lives.

In other news

I got the closest thing yet to an invitation for a date the other night from a resident. Bless his heart, he got all kerfuffled when I started laughing hysterically, right in his face.

Nurses don't date residents. Not, at least, residents that they have to work with. They're residents, after all, and the work-with-this-person-for-years angle doesn't make it any more attractive.

We still have two screamers on the floor. I'm too tired to even consider writing about their latest antics.

The scary nursing student has been booted, not because she's gum on anybody's shoe or because she refused to do maid work, but because she ignored a tonic-clonic seizure one of her patients had and failed to inform the nurse about it.